Recently I’ve been doing some content analysis of the responses people entering our service have to the question ‘What is your goal for pain management?’ The question is designed to find out what it is that people want so that in some way we can work to meet their expectations.
Along similar lines I’ve been pondering the post I wrote about a couple of days ago from Pain for Philosophers – amelioration or obliteration – where the effect of unmet expectations is neatly illustrated.
What happens when a person comes to see you, hoping that your treatment will reduce or perhaps even abolish the pain – but it doesn’t happen?
The content analysis I’ve done so far suggests that almost 70% of the people coming in to a tertiary pain management centre want their pain to be gone or at least significantly reduced. Now I don’t know the actual proportion of people who experience this level of reduction in pain in our centre, but I do know that according to Thorne & Morley, a ‘clinically significant’ change in pain intensity is between 30% and 50%. A far cry from complete removal.
In this study by Thorne & Morely, they ask a group of patients to prospectively identify what would be an acceptable outcome in terms of both pain reduction and improved function (recalling that pain intensity and functional limitations don’t correlate nearly as well as some would hope, it’s probably in the region of 0.4).
The measures used for the study were the Brief Pain Inventory – pain severity and pain impact scales. The severity scale is an 11 point likert-type scale, while the pain impact scales are nine items of daily activity with a 0 – 10 score. The Multidimensional Pain Inventory (West-haven Yale) interference and activity subscales were also used, as was the Hospital Anxiety and Depression Scale to measure mood and anxiety.
The final measure was the Life Orientation Test to measure dispositional optimism. I hadn’t heard of this test – so I’ve included the reference below if you’re keen to study it further.
What they did was ask the participants to complete the questionnaires for their current status. They then asked them to
‘Imagine that you are at a point in the future. Your pain
has not completely stopped, but is now at a level that is more
acceptable to you’. The BPI and MPI were then presented again
with the following instruction. ‘So the pain has changed and is
now at a more acceptable level. Where would that be on this
The first thing to note is that a large proportion of the people asked to participate declined to do so. Thorne & Morely describe the differences between those who agreed and those who didn’t, and although there were more women than men declining, and those who declined tended to be slightly younger, the differences were not thought to be significant. It’s worth keeping in mind though.
Most of the participants had low back pain, painful hips and painful legs, most participants thought they knew the ’cause’ of their pain, and the majority identified that it was as a result of an accident.
The participants appeared, on the basis of their responses to the HADS, to be psychologically distressed – fairly similar, probably, to those typically referred to a tertiary pain management centre.
In terms of the hoped-for reduction in pain and improvement in activity, participants identified they thought a greater than 40% change would be acceptable – the actual range being 44% – 70% improvement. That’s a little different from the typical actual reduction of between 30% – 50%.
The paper details the rest of the statistical analysis, but you know already I’m not going to go into these details here! But a couple of interesting findings from the regression analyses:
- ‘BPI duration of pain and anxiety were significant predictors of larger estimates of the acceptable levels of pain severity and pain impact’
- ‘For both scales derived from the MPI the current level again contributed to the prediction of the acceptable level’
- ‘The HADS again entered into the equation for predicting the acceptable MPI interference score (P = 0.007) and BPI impact score (P = 0.015)’
- ‘In none of the models did the measures of dispositional optimism (LOT-R) or depression (HADS depression) make a significant contribution to the explanatory variance.’
What does this mean for us?
One of the major distinctions of this study is that instead of asking the health professional what an acceptable outcome might be, the patients were asked instead. Standard questionnaires commonly used in pain management outcome measurement were tested to identify whether they ‘work’ well enough to be used in this way by patients.
The average degree of change was more than that typically obtained in pain management – patients want a greater level of pain reduction than can usually be achieved.
The question to ask is what do we do about this discrepancy? As the authors say, a large part of our clinical work could be around simply helping people recognise that much of pain management is up to them – ‘managing the motivational and emotional consequences inherent in such a discrepancy’.
Some patients may well change their expectations from treatment despite not obtaining their original desire – in fact, given that most patients indicate they are satisfied with their treatment, this is probably what happens. A point to note, and raised by Thorne & Morley is that current pain intensity does influence expectation.
There is a current focus on patient-centred care, which at times can sway towards patient-directed care where the patient can dictate some of the approach (and most especially, the ‘endpoint’ of treatment). While I am a strong advocate of patients being involved in all decision-making, after all – you and I are patients of some form or another in our lives! – I am concerned where patients have either insufficient information to make an informed decision, or where their judgements are influenced by cognitive errors to which we are all prone.
One of these errors is the expectation that pain should be able to be abolished. Some treatment providers, and particularly those who focus on pain reduction rather than disability reduction find it very hard to determine when treatment should stop – especially in the face of a distressed patient who simply wants more.
It’s worthwhile reflecting on the role of distress and its influence on reporting pain intensity, and on treatment seeking. This study didn’t appear to directly look at the relationship between distress and treatment expectation – it would be an interesting area to study.
What I’ll take from this study is this: part of my role is to help people move toward accepting that even if pain is present, and it’s more intense than hoped-for, life is still good and there are things we can do to make life better.
Thorne, F., & Morley, S. (2009). Prospective judgments of acceptable outcomes for pain, interference and activity: Patient-determined outcome criteria Pain, 144 (3), 262-269 DOI: 10.1016/j.pain.2009.04.004
Scheier MF, Carver CS. Optimism, coping, and health: assessment and
implications of generalized outcome expectancies. Health Psychol